JMIR Publications

ABSTRACT

Background:

Young people exposed to adverse childhood experiences (ACEs), such as abuse, neglect, bereavement, or family disruption, are at significant risk of poor mental and physical health across the life course. Yet many struggle to access timely help, with long waiting lists and barriers particularly acute for those in minoritised groups or rural and coastal areas. Serious games offer an engaging, scalable, and stigma-reducing approach to supporting young people’s mental health, however, few have been designed specifically for those affected by ACEs, and there is currently no established framework for integrating experience-based co-design (EBCD) with agile game development.

Objective:

This study aimed to (1) develop and apply a novel methodological framework integrating EBCD with agile game development to co-design a serious game with young people affected by ACEs, (2) describe the co-designed game prototype and the design decisions shaped by youth participation, and (3) examine the ethical and safeguarding considerations arising from co-designing digital mental health interventions with trauma-exposed youth.

Methods:

We conducted 12 workshops across 8 iterative co-design sprints over 18 months, involving 18 diverse young people (aged 12–24) with lived experience of ACEs, 5 professional stakeholders, and a multidisciplinary game development team. The process was organised into four phases: (i) understanding ACEs through creative arts, (ii) game concept development, (iii) iterative game development with playtesting and feedback, and (iv) reflection and refinement. We used the GRIPP2 long-form checklist for reporting patient and public involvement and adopted an embedded ethics approach throughout. Participant characteristics were assessed via a baseline survey.

Results:

The resulting prototype, ACE of Hearts, comprised a central “Cosy Den” hub and four mini-games addressing bereavement and caregiving (Horse & Foal), trauma and disability (Dial It Back), gender dysphoria and identity (Out of My Shell), and poverty (Hard Times). Youth feedback directly shaped 47 documented feedback and design decisions across narrative content, game mechanics, visual aesthetics, emotional safety features, and accessibility. Key design innovations included the use of metaphor and multimodal storytelling, the integration of Narrative Exposure Therapy principles into gameplay mechanics, and an embedded ethics framework addressing representation, agency, and emotional safety. Co-design participants (n=14 out of 18 participants) were diverse in gender, ethnicity, sexuality, and neurodivergence, with elevated levels of depression (mean PHQ-9: 8.8, SD 4.5) and anxiety (mean GAD-7: 8.4, SD 3.9).

Conclusions:

This study demonstrates that integrating EBCD with agile development is feasible and productive for creating youth-centred serious games addressing ACEs. The integrated EBCD-Agile framework offers a replicable methodological model for future digital mental health innovation with vulnerable populations. The transparent design decision illustrates how meaningful youth participation shaped substantive game features. Future work should include acceptability and feasibility studies to assess the effectiveness and clinical outcomes.